Owning Attention: Applying Human Factors Principles to Support Clinical Decision Support

In the best examples, clinical decision support (CDS) systems guide clinician decision-making and actions, prevent errors, improve quality, reduce costs, save time, and promote the use of evidence-based recommendations. However, the potential solution that CDS represents are limited by problems associated with improper design, implementation, and local customization. Despite an emphasis on electronic health record usability, little progress has been made to protect end-users from inadequately designed workflows and unnecessary interruptions. Intelligent and personalized design creates an opportunity to tailor CDS not just at the patient level but specific to the disease condition, provider experience, and available resources at the healthcare system level. This chapter leverages the Five Rights of CDS framework to demonstrate the application of human factors engineering principles and emerging trends to optimize data analytics, usability, workflow, and design

Improving Computerized Provider Order Entry Usage in a Community Hospital

The healthcare industry is now faced with the balance between instituting computerized technology and providing safe, high quality, efficient, and lower cost patient care. An important aspect of computer technology is the direct entry of orders electronically by providers into the electronic health record, termed computerized provider order entry (CPOE). This translational research project begins by defining CPOE and discussing CPOE’s effect on patient safety and quality of care by reducing preventable medical errors and adverse drug events and CPOE’s effect on healthcare costs. Regulatory requirements pertaining to CPOE are discussed; providers are expected to be proficient in CPOE in order to meet these requirements. A literature review of barriers to CPOE usage, interventions to implement and improve usage of CPOE, and trends in CPOE usage is conducted and discussed. The purpose of this quality improvement project was to improve CPOE medication order usage among providers within a community hospital by utilizing the provider order entry user satisfaction and usage survey (POEUSUS) to identify barriers to the utilization of CPOE and by employing the technology acceptance model (TAM) and the provision of a CPOE facilitator on the patient care units for twelve hours per week for eight weeks. At the conclusion of the eight-week intervention, the CPOE utilization rates were determined and followed over an eight week interval and were compared to pre-intervention rates. Additionally, providers’ rated their satisfaction of the CPOE facilitator by completing a facilitator survey after each assistance session. The results of this project demonstrated an increase in CPOE medication order usage, from 45.4% CPOE medication order usage during the eight-week pre-intervention period to 55.6% CPOE medication order usage during the eight-week post-intervention period. A statistically significant improvement in provider CPOE satisfaction occurred after the intervention, and providers expressed high degrees of satisfaction with the real-time assistance of the CPOE facilitator. Aspects of CPOE admired by providers and recommendations of providers to changes in CPOE were determined. Finally, age was inversely related and previous computer experiment was positively related to CPOE medication order usage pre-intervention, meaning that younger providers and providers with more computer experience used CPOE more often

Strategies to Mitigate Information Technology Discrepancies in Health Care Organizations

Medication errors increased 64.4% from 2015 to 2018 in the United States due to the use of computerized physician order entry (CPOE) systems and the inability to exchange information among health care facilities. Healthcare information exchange (HIE) and subsequent discrepancies resulted in significant medical errors due to the lack of exchangeable health care information using technology software. The purpose of this qualitative multiple case study was to explore the strategies health care business managers used to manage computerized physician order entry systems within health care facilities to reduce medication errors and increase profitability. The population of the study was 8 clinical business managers in 2 successful small health care clinics located in the mid-Atlantic region of the United States. Data were collected from semistructured interviews with health care leaders and documents from the health care organization as a resource. Inductive analysis was guided by the Donabedian theory and sociotechnical system theory, and trustworthiness of interpretations was confirmed through member checking. Three themes emerged: standardizing data formats reduced medication errors and increased profits, adopting user-friendly HIE reduced medication errors and increase profits, and efficient communication reduced medication errors and increased profits. The findings of this study contribute to positive change through improved health care delivery to patients resulting in healthier communities

Designing Clinical Data Presentation Using Cognitive Task Analysis Methods

Despite the many decades of research on effective use of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practicing dentists in the United States. One critical reason is the poor usability of clinical systems, which makes it difficult for providers to navigate through the system and obtain an integrated view of patient data during patient care. Cognitive science methods have shown significant promise to meaningfully inform and formulate the design, development and assessment of clinical information systems. Most of these methods were applied to evaluate the design of systems after they have been developed. Very few studies, on the other hand, have used cognitive engineering methods to inform the design process for a system itself. It is this gap in knowledge – how cognitive engineering methods can be optimally applied to inform the system design process – that this research seeks to address through this project proposal. This project examined the cognitive processes and information management strategies used by dentists during a typical patient exam and used the results to inform the design of an electronic dental record interface. The resulting 'proof of concept' was evaluated to determine the effectiveness and efficiency of such a cognitively engineered and application flow design. The results of this study contribute to designing clinical systems that provide clinicians with better cognitive support during patient care. Such a system will contribute to enhancing the quality and safety of patient care, and potentially to reducing healthcare costs

The use of evaluation in the design and development of interactive medical record systems

An explorative study was done to develop an evaluation methodology. This method can be applied during the development of interactive medical record systems in order to provide information which can be used to improve user interaction with the system. Th e evaluation methodology consists of a number of interactive sessions with potential users of the interactive medical record system. During the first two sessions the subjects are trained to use the system. During the third and last session the subjects are videotaped while they are doing a set of benchmark tasks on the system under evaluation. The video recordings are analysed to obtain performance data. This performance data consists of task timings and a list of problems experienced (errors made) by the subjects. The systems evaluated during the study were a problem-oriented manual medical record and an interactive computerized medical record. The computerized record system was specifically developed for this study. The design and subsequent improvements to this system are documented in the study

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

The Impact of CPOE Medication Systems’ Design Aspects on Usability, Workflow and Medication Orders

Objectives: To examine the impact of design aspects of computerized physician order entry (CPOE) systems for medication ordering on usability, physicians’ workflow and on medication orders. Methods: We systematically searched Pub - Med, EMBASE and Ovid MEDLINE for articles published from 1986 to 2007. We also evaluated reference lists of reviews and relevant articles captured by our search strategy, and the web-based inventory of evaluation studies in medical informatics 1982–2005. Data about design aspects were extracted from the relevant articles. Identified design aspects were categorized in groups derived from principles for computer screen and dialogue design and user guidance from the International Stan-dard Organization, and if CPOE-specific, from the collected data. Results: A total of 19 papers met our inclusion criteria. Sixteen studies used qualitative evaluation methods and the rest both qualitative and quantitative. In total 42 CPOE design aspects were identified and categorized in seven groups: 1) documentation and data entry components, 2) alerting, 3) visual clues and icons, 4) drop-down lists and menus, 5) safeguards, 6) screen displays, and 7) auxiliary functions. Conclusions: Beside the range of functionalities provided by a CPOE system, their subtle design is important to increase physicians’ adoption and to reduce medication errors. This requires continuous evaluations to investigate whether interfaces of CPOE systems follow normal flow of actions in the ordering process and if they are cognitively easy to understand and use for physicians. This paper provides general recommendations for CPOE (re)design based on the characteristics of CPOE design aspects found

Provider issues related to patient controlled analgesia and nurse controlled analgesia errors in a pediatric hospital

Background: Medical errors are a danger to patient safety and a significant cause of morbidity and mortality. Additionally, they increase expenditures in an already significantly indebted U.S. health care system. Much confusion exists about definitions of medical errors, which include medication errors and adverse drug events (ADEs). Several federal and international organizations have attempted to standardize definitions in order to streamline data collection, but until these standards are universally adopted, error reports and trends are still subject to questions of validity. Reporting errors, in general, has become a more socially acceptable practice in health care with the advent of several anonymous reporting databases. There have also been several initiatives aimed at reducing the incidence of errors, which range from national programs to intrafacility guidelines. Several pieces of health information technology (HIT) have made an impact on error incidence and data collection, although there is much room for improvement. Patient controlled analgesia (PCA) pumps for pain management have been in existence for decades, and "smart pump" software has improved their safety and ease of programming. PCA use in children presents challenges to clinicians, and the characteristics of providers who write PCA orders and those who program PCA pumps may play a role in the incidence of events related to PCA. This study seeks to elucidate trends in errors as they related to these different PCA providers in a pediatric hospital in the northeastern U.S. and provide recommendations for how PCA practice can be improved in this facility. Methods: Safety Event Reporting System (SERS) reports of PCA events (n = 117) during the period of 2004 - 2012 were analyzed retrospectively to determine several key variables for data analysis. The main focus of this analysis was those variable trends related to providers, including: proportion of events caused by human error, proportion of events related to subcategories of human error, proportion of types of prescribers involved in PCA events, proportion of errors in medical and surgical patients, proportion of errors occurring on day and night shifts for the nursing staff, and proportion of events that were dosing mistakes. Statistical analysis was performed for these results when possible to determine significance. Results: Human errors were implicated in 84.1% of events, whereas PCA pump mechanical errors and software errors were implicated in 7.1% and 7.9% of events, respectively. Statistically significant differences were found in all variables tested, including the proportion of nursing errors (60.9%) versus prescriber errors (28.7%) (p < 0.0002). For types of prescribers, the proportion of PCA events occurring when a M.D. wrote the PCA order (56.41%) was statistically different than when a N.P. wrote the PCA order (39.32%) (p = 0.0129). More surgical patients (61.5%) were affected by PCA events than medical patients (36.8%) (p < 0.0002). There were more events occurring on the nursing staff day shift (59.8%) than the night shift (36.8%) (p = 0.0004). Finally, dosing mistakes (66.7%) were implicated in significantly more PCA events than any other error type (33.3%) (p < 0.0002). Conclusion: Several recommendations for improving the safety of PCA in pediatric pain management are justified by the results of this data analysis. First, further education and simulation for entering PCA orders into the CPOE system is needed for all prescribers. Secondly, further education and simulation in PCA pump programming and system set-up is needed for all nursing staff members. In regard to prescriber credentials, it is recommended that Pain Treatment Service (PTS) staff members train M.D. residents in writing PCA orders and entering them into the CPOE system. Finally, it is recommended that the SERS management team publish standardized error report content and entry format in order to streamline data analysis for quality improvement (QI) purposes

Applications of Automated Identification Technology in EHR/EMR

Although both the electronic health record (EHR) and the electronic medical record (EMR) store an individuals computerized health information and the terminologies are often used interchangeably, there are some differences between them. Three primary approaches in Automated Identification Technology (AIT) are barcoding, radio frequency identification (RFID), and biometrics. In this paper, technology intelligence, progress, limitations, and challenges of EHR/EMR are introduced. The applications and challenges of barcoding, RFID, and biometrics in EHR/EMR are presented respectively